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Each Durable Medical Equipment Administrative Contractor (DME MAC) is responsible for processing claims for specific states and territories. Claims must be submitted to the DME MAC that serves the state or territory where the Medicare beneficiary permanently resides.
For example: A supplier is located in California. The supplier provides Medicare-covered items to a Medicare beneficiary who calls Minnesota home for eight months of the year, but who spends about four months in California. The supplier is to submit the claim in to Jurisdiction B where the Medicare beneficiary lives most of the year and not to Jurisdiction D where the supplier is located or where the beneficiary is temporarily living.
Below is a list of each DME MAC and the states and territories they service.
Jurisdiction A is serviced by Noridian Healthcare Solutions and includes Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.
Jurisdiction B is serviced by CGS and includes Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.
Jurisdiction C is serviced by CGS and includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, West Virginia and the US Virgin Islands.
Jurisdiction D is serviced by Noridian Healthcare Solutions and includes Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington and Wyoming,
To view a map of the DME contractors and the areas they service, please click on the links below. Also, the NSC is happy to assist you with questions regarding your supplier file, the Medicare DMEPOS supplier standards, licensure issues and other NSC related topics. If you have questions related to claims, reimbursement, etc., please contact your DME MAC/Region.

HMSA policies and procedures regarding billing requirements and claims filing instructions for durable medical equipment (DME) are consistent with Medicare DME policies except where otherwise specified in the Provider E-Library.

Ophthalmological Benefits

Vision appliances, including contact lenses, are covered as a prosthetic device as outlined in the DME MAC Jurisdiction D Supplier Manual. Eye examinations and appliances for routine refraction are not covered as a medical benefit, but may be covered as a benefit of the member's vision rider, if applicable.

Covered items include:

• Scleral cover shells. Scleral cover shells (HCPCS code V2627) will be considered for coverage as a DME medical benefit when they are medically necessary as an artificial support to a shrunken and sightless eye or as a protective barrier in the treatment of severe dry eye.

• Refractive lenses.

  Refractive lenses, including hydrophilic contact lenses (HCPCS, V2520-V2523) are covered as a DME medical benefit when they are medically necessary to restore the vision normally provided by the natural lens of the eye of an individual lacking the organic lens because of surgical removal or congenital absence. Covered diagnoses are limited to pseodophakia (ICD-9-CM code V43.1; ICD-10-CM code Z96.1), aphakia (ICD-9-CM, 379.31; ICD-10-CM, H27.01,H27.02, H27.03), and congenital aphakia (ICD-9-CM, 743.35; ICD-10-CM, Q12.3). Lenses provided for other diagnoses will be denied as noncovered.

Claims Filing Information

Claims for scleral cover shells and refractive lenses must be submitted with a site-specific modifier - LT and/or -RT and modifier SC to indicate medical necessity and may require additional documentation. Some DME items also require benefit precertification or a certificate of medical necessity. For specific coverage and payment rules, please refer to the DME MAC Jurisdiction D Online Supplier Manual . The manual is available online at www.noridianmedicare.com/dme/news/manual/index.html.

Medicare Advantage Requirements

Dme Mac Supplier Manual

For an item to be covered by Medicare Advantage, a written signed and dated order must have been received by the supplier prior to the item being dispensed and a claim being filed. As Medicare Advantage is Medicare-based, DMERC/Medicare filing guidelines apply.